Rethinking what Women's Health Means
Every health professional should have more of an understanding of the different determinants of health, such as sex and gender. However, physical therapists are in a unique position, in that we see patients throughout the lifespan, with a wide range of previous medical conditions and life experiences. We also get the benefit of increased time with our patients, which opens up the space for patient education. We have a responsibility to make this education as up-to-date and individualized as possible.
This post is inspired by an incredible article that came out this year called Women’s Health Across the Lifespan by McKinney et al.
The article highlights how gender roles in society systematically impact women’s health throughout their lifespan1. When I think of how the term “women’s health” is used, it’s typically synonymous with obstetric or gynecologic care. Conditions such as ACL tears in adolescents and fractures in older adults occur more frequently in women than in men. But is the reason for this imbalance a purely biological phenomenon, or the result of gender-imposed social constructs?
Both sex and gender have a shaping process. There are anatomical and hormonal differences that can impact how people move through life, and gender norms shaping the environment that people grow up in.
Examples include (1) societally influenced body standards for women that contribute to higher rates of dieting, decreased physical labor, and higher rates of osteoporosis (the gender- shaping of biology) and (2) a woman’s pregnancy influencing workplace role and advancement due to perceptions of workplace decision-makers (biologic-shaping of gender).
In my previous post, I detail how important resistance exercise is - however, I recognize there is still a lot of stigma around women lifting heavy weights. I think about Ilona Maher, who is such a huge inspiration of mine, and wish I had more role models like her growing up. The fact is that the socially acceptable female body type is still skinny, but not too skinny, and fit, but not too muscular. These arbitrary and impossible-to-comprehend guidelines make it extremely difficult to move throughout the world in an ever-changing body.
Historically, women have been excluded from medical research as a result of “perceived greater biological complexity” and potential risks to women and their future children. Even today, as more women are included in studies, outcomes are still not frequently grouped by sex or gender - so how can we know if rehabilitation outcomes will be different?
The article goes on to discuss the differences in the way women and girls are perceived throughout their lifespan. Gender bias is prevalent through every stage.
Not even babies are safe from the gender binary. Research shows that although there is no significant difference in motor performance between male and female infants, mothers of male infants overestimated their performance, and mothers of female infants underestimated their performance. Parents will emphasize gross motor skills in males and fine motor skills in females. Babies and young children are incredibly responsible to social and environmental cues. If we are celebrating boys that engage in more “rough and tumble” physical activity, and encouraging girls to play with dolls and kitchen play sets, it will have lifelong impacts. Young girls were also less likely to meet recommendations for physical activity compared to young boys.
Although physical fitness for all children and adolescents has declined, girls are at a disadvantage. Girls report negative body image, sport confidence, physical strength, and self-confidence - all which impact their likelihood of continuing physical fitness. Growing up in an environment that emphasizes fine motor skills, where is the space for improved physical fitness? Speaking for myself, I was never involved in sports in middle school or high school because academics were always the focus. This has historically led to me saying things like, “I have bad coordination,” or “I’m just not that good at sports,” when in reality I didn’t have the practice required to grow those skills2.
Girls and women are at a 3 to 6x higher risk of ACL injury compared to boys and men. In PT school, we learned this statistic with not much else about where it came from, and why this could be the case. Sure, women have higher knee valgus and a wider Q-angle. But again, this is making risk factors out of our typical anatomical structure only when compared to the “norm” of male anatomical structure. If we look at gender as a whole that shapes their bodies, we can dig a little deeper. Girls and women are at a higher likelihood of engaging in disordered or restrictive eating. Couple that with a cultural environment of decreased physical activity, less female representation in sport and coaching staff, and gendered expectations of physical abilities (“you run like a girl”) and it’s no wonder why women may be at higher risk. Male teams also have more funding and access to trained medical staff.
This article has one of my favorite quotes I’ve seen in a research paper - that women act as “shock absorbers” in society both in normal times and times of crisis. When it comes to paid and unpaid caregiving, women contribute at a much higher rate, including child and elder care. This is especially true during the height of the COVID-19 pandemic, when many women were forced to leave the workforce to perform caregiver duties. Coupled with the recent rise in the “trad-wife” and “stay at home girlfriend” trend, and this results in years of missed earning opportunities and systematic de-prioritization of health. Although paid maternity leave results in significantly lower odds of maternal and infant re-hospitalization, as well as higher odds of stress management and physical activity, the US lacks any guaranteed paid leave.
Speaking of maternity, pregnancy and childbirth are not health neutral events - they can lead to conditions including pelvic floor dysfunction (PFD) and hypertensive disorders of pregnancy (HDP). PFDs can include urinary incontinence, fecal incontinence, pelvic organ prolapse, and painful sex - and pregnancy and childbirth are major risk factors. Preeclampsia is the major condition we think of when it comes to HDP’s, which conveys significant health risk for the woman and baby. Any HDP, however, results in increased cardiac risk, such as chronic hypertension, heart failure, coronary artery disease, and cardiovascular mortality. Although we think of smoking and type 2 diabetes as the major risk factors, HDP actually results in a greater risk of CVD. To top it off, women are referred to and attend cardiac rehabilitation in lower numbers than men.
Despite what feels like biologic and systematic disadvantage, women have higher life expectancy than men worldwide. (This has stumped researchers.) However, women are more likely to be in poorer health towards the end of their life. (Probably not as shocking.) Overall motor performance decreases with age, and older women perform worse than older men: however, to me this is not surprising as we see a common thread of lack of physical activity and de-prioritization of resistance training throughout the lifespan. In addition, women are less likely to work in jobs that require manual labor or be responsible for more physical tasks around the home - again, gendered differences in mowing the lawn vs doing the dishes and laundry. Through this lens, we can look at osteoporosis a little differently - could it be caused by differences in hormones, or systematic de-prioritization of physical activity, higher rates of dieting and caloric restriction impacting bone health, and social pressure related to what your body is supposed to look like?
Finally, we come to urinary incontinence. Unfortunately, I see patients who struggle with this daily - and the incidence and severity only increases with age. UI limits function in a multitude of ways. It results in social isolation, prevents physical activity resulting in further decline of function, and limits overall daily activities. This results in higher rates of sarcopenia (muscle loss) and gait and balance impairments.
If you couldn’t tell by the length of this post, this is a topic incredibly important to me. This is by no means me saying men do not suffer from pelvic floor dysfunction - they absolutely do. However, when you focus on underserved communities, everyone benefits. If pelvic floor care is given more attention, then everyone who struggles will have better access to care.
some important things to note: the term “women” is inclusive of sex as a biological variable and gender as a social variable - including people assigned female at birth, transgender women, transgender men, and nonbinary people. In addition, “women’s health” is used to discuss conditions that affect primarily women or present differently in women, including but not limited to sexual and reproductive health (SRH). This article also does not take into consideration the impact of race or socioeconomic status, but instead focuses on the gender binary and how it impacts health outcomes.
2
I have recently picked up tennis, and through practice and cross training have gotten pretty good. Good enough to keep playing, and to keep my husband on his toes. But in the beginning, I was sure that my “terrible” hand-eye coordination would stop me from making any progress.
